BECOME A DEALER FORM

FILL UP THE APPLICATION BELOW TO BECOME A DEALER TO BE ABLE TO ORDER PHONES.

* Required

COMPANY NAME
*

This is a required question

DBA (if any)

This is a required question

FEDERAL TAX ID
*

This is a required question

TYPE OF BUSINESS
*

( PARTNERSHIP , SOLE PRORIETORSHIP, CORPORATION, LLC )

This is a required question

FULL NAME
*

This is a required question

STREET ADDRESS
*

This is a required question

CITY
*

This is a required question

STATE
*

This is a required question

ZIP CODE
*

This is a required question

WORK NUMBER
*

This is a required question

MOBILE NUMBER
*

This is a required question

EMAIL ADDRESS
*

This is a required question

TRADE REFERENCES
*

COMPANY NAME

This is a required question

TRADE REFERENCES
*

CONTACT PHONE #

This is a required question

TRADE REFERENCES
*

CONTACT NAME #

This is a required question

TRADE REFERENCES

COMPANY ADDRESS

This is a required question

TRADE REFERENCES # 2
*

COMPANY NAME

This is a required question

TRADE REFERENCES # 2
*

CONTACT PHONE #

This is a required question

TRADE REFERENCES # 2
*

CONTACT NAME #

This is a required question

TRADE REFERENCES # 2

COMPANY ADDRESS

This is a required question

I hereby certify that the information presented on this application is correct to the best of my knowledge. My signature below constitutes an authorization for Cell 2 Talk, Inc. to contact the above references so that Cell 2 Talk, Inc. can establish an account on my behalf.
*